Sunday, June 26, 2011

Appointment Phishing

“Hi, my name is Alexis Jackson, and I’m calling to schedule the next available appointment with Dr. Michael Krane. I am a new patient with a P.P.O. from Aetna. I just moved to the area and don’t yet have a primary doctor, but I need to be seen as soon as possible.”

Doctor’s office: “What type of problem are you experiencing?”

Patient: “I’ve had a cough for the last two weeks, and now I’m running a fever. I’ve been coughing up thick greenish mucus that has some blood in it, and I’m a little short of breath.”

Upon hearing his, you cancel two other follow-up patient appointments to make room for this longer new-patient appointment. Sadly, you later find that "Alexis Jackson" isn't a real patient but rather a decoy - a so-called "mystery shopper" paid by our government - just so that wait times for your appointment could be determined.

Most patients I know would understand a doctors' need to make room for a new patient with an urgent problem. But I am also quite certain that most of my patients would not tolerate finding out that a government-paid stand-in lied to me and intruded on their care just so the government could gather information on my appointment availability.

When information gathering trumps patient care - particularly fictitious care - we've got a problem. Is this a new quality standard we can expect from our new government health care initiative?

Just like scam-artists that phish for unsuspecting people's financial information online, governmental appointment phishing should not be tolerated in any way, shape, or form. It is fraud - plain and simple.

Otherwise, many people's health care will be adversely affected as a result.

The hypothetical Dr. Krane example is such a lose-lose situation. The doctor has jeopardized his relationship with the rescheduled existing patient for a fake (scam?) caller, and the established patient has had their life effected (scheduling etc.) for no reason too. If I am that established patient (who, indeed, would understand the need for a reschedule for a legitimate reason), I would be royally ticked that I had to rearrange my life for nothing: I have multiple things to schedule, transportation issues to account for, anxieties about my own medical issues that prompted me to schedule my appt to begin with etc. as well.

So let me ask a serious (not snarky) question: what do you see as the harm for "Dr. Krane's" offic to say to the fake caller: We cannot accept you as a new patient right now, as our schedule does not have any openings that would allow us to see you in the timely manner your condition seems to require. Here are some numbers for other practitioners in the area that may be able to see you in a more timely fashion. (OK, maybe not those exact words, but you get my drift.) I know you do not want to send folks to "the competition" but this response incorporates honesty to the "new patient", respect for your established patient, and respect for your own boundaries and limitations.

Wes, there was no suggestion in the original NYT article that the mystery shoppers would actually make an appointment. I don't see any problem with the government trying to independently assess the degree to which citizen of the US are having trouble getting primary care. This seems to me exactly what the government should be doing!

GREAT scenario to ponder. My thoughts: Offering an alternative center makes sense for the patient in need of urgent care and is ethically responsible. For the doctor-employee who is part of a large health care system (ACO?) competing for new patients (that typically pay the system better than follow-up patients), this behavior I'm sad to say, if repetitive, would be tacitly frowned upon by the hospital corporate heirarchy. Ironically, it might be the very behavior that would win favor with patients, however.

Larry -

If we go this retail route, we should ask ourselves why the heck we're paying for national electronic medical records that already contain all this information and are completely non-biased. Is there really a need to have "mystery shoppers" (ugh) for health care? Why not address the REAL problem: a national shortage of primary care physicians instead? This top-down, ham-handed and (frankly) dishonest way to manipulate physicians is intolerable on so many levels. *(BTW, the scenario I proposed was quoted from the NYT article.)

The very fact that the AMA has sanctioned this practice via their "ethics council" speaks volumes about their disconnect from the real doctors seeing real patients on the frontline of medical care in the US today.

"we should ask ourselves why the heck we're paying for national electronic medical records that already contain all this information"

Even assuming EMRs note how many days a patient had to wait between call and appointment (and I don't believe they do), there is no medical record for a patient who can't get an appointment, and no indication when they do get one if they've been calling around for days or weeks before finding a practice accepting new patients.

As for repercussions, there are none for the practice, no matter how they respond. The plan is to collect anonymous data to determine, both before and after full implementation of the Affordable Care Act, how long it takes new patients to get in to see a PCP. I don't think the scenario chosen (persistent cough, fever, some blood in thick mucus, and SOB) is a particularly good one, since any doc concerned about the possibility of a pulmonary embolism is likely to send the patient to the ED.

As a patient, I am frustrated when I have to reschedule an appointment. Especially when the appointment is for a specialist that I have to call ahead six months to get an appointment, and especially when the appointment can't be rescheduled within a week of the original appointment. I only get upset at the practice if it is a recurrent problem. I have left the practice of doctors that I really trusted for this reason. I think that it is hideous for the government or anyone else to jeopardize my medical care and relationship with my doctors for research.

Maybe a few more facts will be helpful. Survey to cover only nine states - less than 500 docs in each state to be called. Each office in the survey will be contacted at least twice - no more than three.

I think somebody could come up with a better idea, but this is not a widespread, nationwide, uncontrolled survey. Just in case you were wondering...

The scenario doesn't seem realistic. Long ago we moved, and while I was in the process of looking for a doctor, my daughter injured herself. I called our old doctor 90 minutes away and they said they'd be happy to see us when we could get there, but recommended phoning someone local. I called one of the local places I was considering and explained the situation. They said they'd be happy to fit us in. Nobody was cancelled, though. I went and sat in their waiting room (with a toddler who was crying in pain) all afternoon. She was the last patient of the day to be seen. We were not "squeezed in." We were tacked on to the end of the day, and my daughter was in pain much longer than necessary. We should have gone back to her old doctor.

I mind. I schedule my appointments to cost the least amount possible, and it costs me extra when my doctor reschedules. In addition to the extra money it costs, it is highly inconvenient for the six people whose schedules have to be coordinated with mine.

I understand being rescheduled because the doctor got sick. I even understand being rescheduled because the doctor's child got sick. It is expensive and inconvenient; I don't like it, but I understand. I would not understand being stood up so you could take on a new patient.

I suspect you're correct in thinking that existing scheduling software date-stamps when an appointment is made. It should be very easy to get a report that shows what the lead time is on appointments. No need for all the phishing.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.